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Shen B. Endoscopic Evaluation of the Ileal Pouch. Dis Colon Rectum 2024; 67:S52-S69. [PMID: 38276962 DOI: 10.1097/dcr.0000000000003269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and IPAA. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. OBJECTIVE A systematic review of the literature was performed, and principles and techniques of pouchoscopy were described. DATA SOURCES PubMed, Google Scholar, and Cochrane databases. STUDY SELECTION Relevant articles on endoscopy in ileal pouches published between January 2000 and May 2023 were included based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. MAIN OUTCOME MEASURES Accurate characterization of the ileal pouch in healthy or diseased states. RESULTS The main anatomic structures of a J- or S-pouch are the stoma closure site, prepouch ileum, inlet, tip of the "J," pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the "J" and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. LIMITATIONS This is a qualitative, not quantitative, review of mainly case series. CONCLUSIONS Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch and be able to recognize common abnormalities. See video from symposium.
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Affiliation(s)
- Bo Shen
- The Global Integrated Center for Colorectal Surgery and Interventional Endoscopy and Center for Inflammatory Bowel Diseases, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York
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2
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Wang Y, He Q, Yao D, Huang Y, Xia W, Chen W, Cui Z, Li Y. Histological Image-based Ensemble Model to Identify Myenteric Plexitis and Predict Endoscopic Postoperative Recurrence in Crohn's Disease: A Multicentre, Retrospective Study. J Crohns Colitis 2024; 18:727-737. [PMID: 38001024 DOI: 10.1093/ecco-jcc/jjad196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND AND AIMS Myenteric plexitis is correlated with postoperative recurrence of Crohn's disease when relying on traditional statistical methods. However, comprehensive assessment of myenteric plexus remains challenging. This study aimed to develop and validate a deep learning system to predict postoperative recurrence through automatic screening and identification of features of the muscular layer and myenteric plexus. METHODS We retrospectively reviewed 205 patients who underwent bowel resection surgery from two hospitals. Patients were divided into a training cohort [n = 108], an internal validation cohort [n = 47], and an external validation cohort [n = 50]. A total of 190 960 patches from 278 whole-slide images of surgical specimens were analysed using the ResNet50 encoder, and 6144 features were extracted after transfer learning. We used five robust algorithms to construct classification models. The performances of the models were evaluated based on the area under the receiver operating characteristic curve [AUC] in three cohorts. RESULTS The stacking model achieved satisfactory accuracy in predicting postoperative recurrence of CD in the training cohort (AUC: 0.980; 95% confidence interval [CI] 0.960-0.999), internal validation cohort [AUC: 0.908; 95% CI 0.823-0.992], and external validation cohort [AUC: 0.868; 95% CI 0.761-0.975]. The accuracy for identifying the severity of myenteric plexitis was 0.833, 0.745, and 0.694 in the training, internal validation and external validation cohorts, respectively. CONCLUSIONS Our work initially established an interpretable stacking model based on features of the muscular layer and myenteric plexus extracted from histological images to identify the severity of myenteric plexitis and predict postoperative recurrence of CD.
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Affiliation(s)
- Yuexin Wang
- Department of General Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi He
- Department of General Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Danhua Yao
- Department of General Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuhua Huang
- Department of General Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenwen Xia
- Department of Pathology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weilin Chen
- Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhe Cui
- Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yousheng Li
- Department of General Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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3
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Mañosa M, Rivière P, de Greef I, Oller B, Roig C, Calafat M, Garcia-Planella E, Laharie D, Ferrante M, Domènech E. Long-term risk of delayed postoperative Crohn's disease recurrence in patients with no or mild endoscopic recurrence at first assessment. Eur J Clin Invest 2024:e14219. [PMID: 38647188 DOI: 10.1111/eci.14219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/25/2024] [Accepted: 03/29/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Early endoscopic evaluation is recommended for assessment of postoperative recurrence (POR) of Crohn's disease (CD) but no further monitoring recommendations are available. AIM To evaluate the long-term outcome of patients without endoscopic POR at first endoscopic assessment. METHODS Retrospective four-centre study including consecutive CD patients with ileocolonic resection (ICR) without endoscopic POR (Rutgeerts score i0-i1) at first endoscopic assessment performed within 18 months from ICR. All patients had a clinical follow-up ≥24 months and at least one further endoscopic assessment. Main outcomes were endoscopic, clinical and surgical POR, need for rescue therapy and "delayed POR" (any need for rescue therapy or clinical or surgical POR) during follow-up. RESULTS Overall, 183 patients were included (79% with risk factors for POR, 44% without postoperative prophylaxis). Endoscopic POR was observed in 42% of patients. Clinical POR-free survival was 89.4% and 81.5% at 3 and 5 years, and delayed POR-free survival was 76.9% and 63.4% at 5 and 10 years, respectively. In multivariate analysis, postoperative prophylaxis (HR .55; 95% CI .325-.942) and active smoking (HR 1.72; 95%CI 1.003-2.962) were independent risk factors for clinical POR, whereas presence of mild endoscopic lesions at index ileocolonoscopy (i1) was the only risk factor for delayed POR (HR 1.824; 95% CI 1.108-3.002). CONCLUSIONS Long-term risk of POR among patients with no or mild endoscopic lesions at first ileocolonoscopy after surgery is steadily low, being higher among smokers, in the absence of postoperative prophylaxis and when mild endoscopic lesions are observed in the first endoscopic assessment.
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Affiliation(s)
- Míriam Mañosa
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Pauline Rivière
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, CHU de Bordeaux, Bordeaux, France
- INSERM CIC 1401, Bordeaux, France
| | - Ine de Greef
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Blanca Oller
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Cristina Roig
- Hospital de la Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Margalida Calafat
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - David Laharie
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, CHU de Bordeaux, Bordeaux, France
- INSERM CIC 1401, Bordeaux, France
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Eugeni Domènech
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
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Ollech JE, Yanai H. Navigating Postoperative Management in Crohn's Disease: Insights from the PORCSE Study. J Crohns Colitis 2024:jjae054. [PMID: 38642911 DOI: 10.1093/ecco-jcc/jjae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2024]
Affiliation(s)
- Jacob E Ollech
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
- Affiliated with the Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
- Affiliated with the Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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5
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Bak MT, ten Bokkel Huinink S, Erler NS, Bodelier AG, Dijkstra G, Romberg-Camps M, de Boer NK, Hoentjen F, Stassen LP, van der Meulen–de Jong AE, West RL, van Ruler O, van der Woude CJ, de Vries AC. Prognostic Value of the Modified Rutgeerts Score for Long-Term Outcomes After Primary Ileocecal Resection in Crohn's Disease. Am J Gastroenterol 2024; 119:306-312. [PMID: 37737675 PMCID: PMC10833187 DOI: 10.14309/ajg.0000000000002509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION The prognostic value of the modified Rutgeerts score (mRS) in patients with Crohn's disease (CD) needs to be further elucidated. This study assessed the prognostic value of the mRS for long-term outcomes after primary ileocecal resection in patients with CD. METHODS Patients with CD after primary ileocecal resection with an available mRS at first postoperative ileocolonoscopy (index mRS) were retrospectively included. The primary outcome was surgical recurrence. Secondary outcomes were clinical recurrence and progression to severe endoscopic recurrence (≥i3). Cox proportional hazard models were used to assess the association between index mRS and outcomes. RESULTS Six hundred fifty-two patients were included (mean follow-up: 6.4 years, SD: 4.6). Surgical recurrence rates were 7.7%, 5.3%, 12.9%, 19.1%, 28.8%, 47.8% for index mRS i0, i1, i2a, i2b, i3, and i4, respectively. Clinical recurrence occurred in 42.2% (i0), 53.7% (i1), 58.5% (i2a), 80.2% (i2b), 79.4% (i3), and 95.3% (i4) of patients. Progression to severe endoscopic recurrence occurred in 21.1% (i0), 33.9% (i1), 26.8% (i2a), and 33.3% (i2b) of patients. An index mRS of i2b (adjusted hazard ratio [aHR] 3.0; 1.5-5.6), i3 (aHR 4.0; 2.0-7.9) and i4 (aHR 8.0; 4.0-16.0) were associated with surgical recurrence. An index mRS of i1 (aHR 1.7; 1.2-2.4), i2a (aHR 1.7; 1.2-2.4), i2b (aHR 4.4; 3.2-6.0), i3 (aHR 3.6; 2.5-5.2), and i4 (aHR 7.3; 4.8-10.9) were associated with clinical recurrence. An index mRS of i1 (aHR 2.0; 1.1-3.7) or i2b (aHR 2.5; 1.4-4.6) was associated with progression to severe endoscopic recurrence. DISCUSSION The increasing mRS corresponds closely with the risk of surgical and clinical recurrence. An index mRS ≥ i2b is associated with surgical recurrence, an index mRS ≥ i1 is associated with clinical recurrence, and i1 or i2b with progression to severe endoscopic recurrence. These results support tight monitoring of disease activity and treatment optimization in patients with ileal lesions and a more conservative management in patients with anastomotic lesions.
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Affiliation(s)
- Michiel T.J. Bak
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sebastiaan ten Bokkel Huinink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nicole S. Erler
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Mariëlle Romberg-Camps
- Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Centre, Heerlen-Sittard-Geleen, the Netherlands
| | - Nanne K.H. de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, Canada;
| | - Laurents P.S. Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Rachel L. West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Oddeke van Ruler
- Department of Surgery, IJsselland Ziekenhuis, Cappelle aan den IJssel, the Netherlands
- Department of Surgery, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C. Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annemarie C. de Vries
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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Bachour SP, Click BH. Clinical Update on the Prevention and Management of Postoperative Crohn's Disease Recurrence. Curr Gastroenterol Rep 2024; 26:41-52. [PMID: 38227128 DOI: 10.1007/s11894-023-00911-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE OF REVIEW Despite advances in therapeutics, a significant portion of patients with Crohn's disease still require surgical management. In this article, we present updates to the natural history, prognostication and postoperative monitoring, and novel therapeutics in the prevention and treatment of postoperative Crohn's disease recurrence. RECENT FINDINGS Clinical risk factors have been associated with higher rates of postoperative recurrence (POR), and in recent studies demonstrate an increased cumulative risk with presence of additional risk factors. Additional novel clinical, histologic, and "-omic" risk factors for recurrence have recently been elucidated, including the role of the mesentery on recurrence and perioperative intraabdominal septic complications. High-risk patients benefit most from medical prophylaxis, including anti-TNF with or without immunomodulator therapy to prevent recurrence. New biologics such as vedolizumab and ustekinumab have emerging evidence in the use of prophylaxis, especially with recent REPREVIO trial data. Non-invasive disease monitoring, such as cross-sectional enterography, intestinal ultrasound, and fecal calprotectin, have been validated against ileocolonoscopy. Recent advances in the prediction, prevention, and monitoring algorithms of postoperative Crohn's disease may be leading to a reduction in postoperative recurrence. Ongoing trials will help determine optimal monitoring and management strategies for this at-risk population.
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Affiliation(s)
- Salam P Bachour
- Brigham and Women's Hospital, Department of Medicine, Boston, MA, 02115, USA
| | - Benjamin H Click
- University of Colorado Anschutz Medical Campus, Division of Gastroenterology and Hepatology, 13001 E 17th Pl, Aurora, CO, 80045, USA.
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Ueda T, Koyama F, Sugita A, Ikeuchi H, Futami K, Fukushima K, Nezu R, Iijima H, Mizushima T, Itabashi M, Watanabe K, Hata K, Shinagawa T, Matsuoka K, Takenaka K, Sasaki M, Nagayama M, Yamamoto H, Shinozaki M, Fujiya M, Kato J, Ueno Y, Tanaka S, Okita Y, Hashimoto Y, Kobayashi T, Koganei K, Uchino M, Fujii H, Suzuki Y, Hisamatsu T. Endoscopic Lesions of Postoperative Anastomotic Area in Patients With Crohn's Disease in the Biologic Era: A Japanese Multi-Centre Nationwide Cohort Study. J Crohns Colitis 2023; 17:1968-1979. [PMID: 37450892 DOI: 10.1093/ecco-jcc/jjad116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND AIMS Many patients have endoscopic evidence of recurrent Crohn's disease [CD] at 1 year after intestinal resection. These lesions predict future clinical recurrence. We endoscopically evaluated postoperative anastomotic lesions in CD patients from a large cohort of postoperative CD patients. METHODS We retrospectively enrolled CD patients who underwent surgical resection between 2008 and 2013 at 19 inflammatory bowel disease [IBD]-specialist institutions. The initial analyses included patients who underwent ileocolonoscopy ~1 year after intestinal resection. Follow-up analyses assessed any changes in the endoscopic findings over time. We evaluated the postoperative endoscopic findings, which were classified into four categories [no lesion, mild, intermediate, severe] at the sites of the anastomotic line and peri-anastomosis. RESULTS In total, 267 CD patients underwent postoperative ileocolonoscopy. Postoperative anastomotic lesions were widely detected in index ileocolonoscopy [61.0%] and were more frequently detected in follow-up ileocolonoscopy [74.9%]. Endoscopic severity also increased. Patients with intermediate or severe peri-anastomotic or anastomotic line lesions at the index ileocolonoscopy required significantly more interventions, including endoscopic dilatation or surgery, than patients with mild lesions or no lesions. CONCLUSIONS Frequent anastomotic lesions were observed at the postoperative index ileocolonoscopy. These gradually increased for subsequent ileocolonoscopy, even in the biologic era. Regarding lesions on the anastomotic line, intermediate lesions on the anastomotic line [e.g. irregular or deep ulcers] might be considered recurrent disease, and mild lesions [e.g. linear superficial ulcers] might be considered non-recurrent disease. Prospective studies are needed to resolve this issue, including treatment enhancement.
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Affiliation(s)
- Takeshi Ueda
- Department of Surgery, Nara Medical University, Kashihara, Japan
- Sai Gastroenterology and Proctology Clinic, Fujiidera, Japan
| | - Fumikazu Koyama
- Department of Surgery, Nara Medical University, Kashihara, Japan
- Division of Endoscopy, Nara Medical University Hospital, Kashihara, Japan
| | - Akira Sugita
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Hiroki Ikeuchi
- Department of Gastroenterological Surgery, Division of Inflammatory Bowel Disease Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kitaro Futami
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | | | - Riichiro Nezu
- Department of Surgery, Osaka Central Hospital, Osaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, and Department of Gastroenterology, Department of Gastroenterology, Osaka Police Hospital, Osaka, Japan
| | - Tsunekazu Mizushima
- Department of Therapeutics for Inflammatory Bowel Diseases, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Michio Itabashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
- Nihonbashi Muromachi Mitsui Tower Midtown Clinic, Tokyo, Japan
| | | | - Katsuyoshi Matsuoka
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Makoto Sasaki
- Division of Gastroenterology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Manabu Nagayama
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Hironori Yamamoto
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Masaru Shinozaki
- Department of Surgery, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan, and Saitama Gastroenterological Clinic, Saitama, Japan
| | - Mikihiro Fujiya
- Gastroenterology and Endoscopy, Division of Metabolism and Biosystemic Science, Gastroenterology, and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Jun Kato
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshitaka Ueno
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshiki Okita
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | | | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kazutaka Koganei
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Motoi Uchino
- Department of Gastroenterological Surgery, Division of Inflammatory Bowel Disease Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Hisao Fujii
- Gastrointestinal Endoscopy and IBD Center, Yoshida Hospital, Nara, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
- Ginza Central Clinic, Tokyo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo, Japan
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Fasulo E, D’Amico F, Osorio L, Allocca M, Fiorino G, Zilli A, Parigi TL, Danese S, Furfaro F. The Management of Postoperative Recurrence in Crohn's Disease. J Clin Med 2023; 13:119. [PMID: 38202126 PMCID: PMC10779955 DOI: 10.3390/jcm13010119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/20/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
Crohn's disease (CD) is a chronic inflammatory bowel disease with different phenotypes of presentation, inflammatory, penetrating, or stricturing disease, that significantly impacts patient well-being and quality of life. Despite advances in medical therapy, surgery sometimes represents the only treatment to address complications, such as strictures, fistulas, or abscesses. Minimizing postoperative recurrence (POR) remains a major challenge for both clinicians and patients; consequently, various therapeutic strategies have been developed to prevent or delay POR. The current review outlines an updated overview of POR management. We focused on diagnostic assessment, which included endoscopic examination, biochemical analyses, and cross-sectional imaging techniques, all crucial tools used to accurately diagnose this condition. Additionally, we delved into the associated risk factors contributing to POR development. Furthermore, we examined recent advances in the prophylaxis and treatment of POR in CD.
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Affiliation(s)
- Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Ferdinando D’Amico
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20089 Milan, Italy
| | - Laura Osorio
- Gastroenterologist Hospital Pablo Tobon Uribe, Medellín 050010, Colombia;
| | - Mariangela Allocca
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Gionata Fiorino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Alessandra Zilli
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Tommaso Lorenzo Parigi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
- Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Federica Furfaro
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (E.F.); (F.D.); (M.A.); (G.F.); (A.Z.); (S.D.)
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9
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Nardone OM, Calabrese G, Barberio B, Giglio MC, Castiglione F, Luglio G, Savarino E, Ghosh S, Iacucci M. Rates of Endoscopic Recurrence In Postoperative Crohn's Disease Based on Anastomotic Techniques: A Systematic Review And Meta-Analysis. Inflamm Bowel Dis 2023:izad252. [PMID: 37931290 DOI: 10.1093/ibd/izad252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Patients with Crohn's disease (CD) after ileocolic resection may develop an endoscopic postoperative recurrence (ePOR) that reaches 40% to 70% of incidence within 6 months. Recently, there has been growing interest in the potential effect of anastomotic configurations on ePOR. Kono-S anastomosis has been proposed for reducing the risk of clinical and ePOR. Most studies have assessed the association of ileocolonic anastomosis and ePOR individually, while there is currently limited data simultaneously comparing several types of anastomosis. Therefore, we performed a systematic review and meta-analysis to assess the impact of different ileocolonic anastomosis on ePOR in CD. METHODS We searched PubMed and Embase from inception to January 2023 for eligible studies reporting the types of anastomoses and, based on these, the rate of endoscopic recurrence at ≥6 months. Studies were grouped by conventional anastomosis, including side-to-side, end-to-end, and end-to-side vs Kono-S, and comparisons were made between these groups. Pooled incidence rates of ePOR were computed using random-effect modelling. RESULTS Seventeen studies, with 2087 patients who underwent ileocolic resection for CD were included. Among these patients, 369 (17,7%) Kono-S anastomoses were performed, while 1690 (81,0%) were conventional ileocolic anastomosis. Endoscopic postoperative recurrence at ≥6 months showed a pooled incidence of 37.2% (95% CI, 27.7-47.2) with significant heterogeneity among the studies (P < .0001). In detail, patients receiving a Kono-S anastomosis had a pooled incidence of ePOR of 24.7% (95% CI, 6.8%-49.4%), while patients receiving a conventional anastomosis had an ePOR of 42.6% (95% CI, 32.2%-53.4%). CONCLUSIONS Kono-S ileocolic anastomosis was more likely to decrease the risk of ePOR at ≥6 months compared with conventional anastomosis. Our findings highlight the need to implement the use of Kono-S anastomosis, particularly for difficult to treat patients. However, results from larger randomized controlled trials are needed to confirm these data.
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Affiliation(s)
- Olga Maria Nardone
- Gastroenterology, Department of Public Health, School of Medicine, Federico II University of Naples, Naples, Italy
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Giulio Calabrese
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery Oncology and Gastroenterology DiSCOG, University of Padova, Padova, Italy
| | - Mariano Cesare Giglio
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Fabiana Castiglione
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine, Federico II University of Naples, Naples, Italy
| | - Gaetano Luglio
- Department of Public Health, Endoscopic Surgery Unit, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery Oncology and Gastroenterology DiSCOG, University of Padova, Padova, Italy
| | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, College Road, National University of Ireland, T12 K8AF Cork, Ireland
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, College Road, National University of Ireland, T12 K8AF Cork, Ireland
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10
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Evaristo G, Szczepanski J, Farag MS, Rubin DT, Campbell LK, Marcus VA, Lamps LW, Hart J. Crohn's Disease Features in Anastomotic Biopsies from Patients With and Without Crohn's Disease: Diagnostic and Prognostic Value. Mod Pathol 2023; 36:100325. [PMID: 37660927 DOI: 10.1016/j.modpat.2023.100325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Abstract
Endoscopic evidence of disease activity is a critical predictor of clinical relapse in patients with Crohn's disease (CD), and histologic disease activity is evolving as a similarly important end point for patient management. However, classical morphologic features of CD may overlap with postoperative inflammatory changes, confounding the evaluation of anastomotic biopsies. There is a clear unmet need for better characterization of diagnostic and clinically significant histologic features of CD in these surgically altered sites. We evaluated ileocolonic and colocolonic/rectal anastomotic biopsies performed at 3 academic institutions in patients with and without CD. The biopsies were blindly assessed for CD histologic features and correlated to clinical and endoscopic characteristics. In CD patients, the presence of each feature was correlated with the subsequent clinical exacerbation or relapse. We obtained anastomotic biopsies from 208 patients, of which 109 were operated on for CD and 99 for another indication (neoplasia [80%], diverticular disease (11%), and other [9%]). Mean time since surgery was 10 years (0-59; 14 years for CD [1-59], 6 years for non-CD [0-33]). Endoscopic inflammation was noted in 52% of cases (68% for CD and 35% for non-CD). Microscopic inflammation was present in 74% of cases (82% for CD and 67% for non-CD). Only discontinuous lymphoplasmacytosis (P < .001) and pyloric gland metaplasia (P = .04) occurred significantly more often in CD patients. However, none of the histologic features predicted clinical disease progression. In subset analysis, the presence of histologic features of CD in nonanastomotic biopsies obtained concurrently in CD patients was significantly associated with relapse (P = .03). Due to extensive morphologic overlap between CD and postoperative changes and the lack of specific histologic features of relapse, biopsies from anastomotic sites are of no value in predicting clinical CD progression. Instead, CD activity in biopsies obtained away from anastomotic sites should be used for guiding endoscopic sampling and clinical management.
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Affiliation(s)
| | | | - Mina S Farag
- Department of Pathology, McGill University, Montreal, Quebec, Canada
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Ilinois
| | | | - Victoria A Marcus
- Department of Pathology, McGill University, Montreal, Quebec, Canada
| | - Laura W Lamps
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - John Hart
- Department of Pathology, University of Chicago, Chicago, Illinois.
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11
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Dragoni G, Allocca M, Myrelid P, Noor NM, Hammoudi N, Rivière P, Panis Y, Ferrante M. Results of the Eighth Scientific Workshop of ECCO: Diagnosing Postoperative Recurrence of Crohn's Disease After an Ileocolonic Resection With Ileocolonic Anastomosis. J Crohns Colitis 2023; 17:1373-1386. [PMID: 37070339 DOI: 10.1093/ecco-jcc/jjad055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 04/19/2023]
Abstract
Despite the introduction of potent biologic therapies, many patients with Crohn's disease [CD] still require an ileocolonic resection [ICR] during the course of their disease. Furthermore, the need of redo ICR has not decreased over the past few decades, highlighting the need for better strategies to prevent and treat postoperative recurrence [POR]. The first step to develop such a strategy would be to define and standardise the description of POR with adequate diagnostic instruments. In this article, we will describe the different methodologies used to report POR [endoscopic, histological, radiological, biochemical, clinical, and surgical], and review their potential benefits and limitations, as well as the optimal timing of evaluation.
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Affiliation(s)
- Gabriele Dragoni
- IBD Referral Center, Department of Gastroenterology, Careggi University Hospital, Florence, Italy
- Gastroenterology Research Unit, Department of Experimental and Clinical Biochemical Sciences 'Mario Serio', University of Florence, Florence, Italy
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nurulamin M Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nassim Hammoudi
- Gastroenterology Department, Hôpital Saint-Louis - APHP, Université Paris Cité, INSERM U1160, Paris, France
| | - Pauline Rivière
- Department of Gastroenterology and Hepatology, Centre Médico-chirurgical Magellan, Hôpital Haut-Lévêque, CHU de Bordeaux, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Yves Panis
- Paris IBD Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research in Gastrointestinal Disorders [TARGID], Department of Chronic Diseases and Metabolism [CHROMETA], KU Leuven, Leuven, Belgium
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12
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Xiong S, He J, Chen B, He Y, Zeng Z, Chen M, Chen Z, Qiu Y, Mao R. A nomogram incorporating ileal and anastomotic lesions separately to predict the long-term outcome of Crohn's disease after ileocolonic resection. Therap Adv Gastroenterol 2023; 16:17562848231198933. [PMID: 37720355 PMCID: PMC10503285 DOI: 10.1177/17562848231198933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Background The Rutgeerts score (RS) is widely used to predict postoperative recurrence after ileocolonic resection for Crohn's disease (CD) based on the severity of lesions at the neoterminal ileum and anastomosis (RS i0-i4). However, the value of anastomotic ulcers remains controversial. Objectives Our aim was to establish a nomogram model incorporating ileal and anastomotic lesions separately to predict the long-term outcomes of CD after ileal or ileocolonic resection. Design A total of 136 patients with CD were included in this retrospective cohort study. Methods Consecutive CD patients who underwent ileal or ileocolonic resections with postoperative ileocolonoscopy evaluation within 1 year after the surgery were included. The primary endpoint was postoperative clinical relapse (CR). An endoscopic classification separating ileal and anastomotic lesions was applied (Ix for neoterminal ileum lesions; Ax for anastomotic lesions). A nomogram was constructed to predict CR. The performance of the model was evaluated by the receiver-operating characteristic (ROC) curve and decision curve analysis (DCA). Results CR was observed in 47.1% (n = 64) of patients within a median follow-up of 26.9 (interquartile range, 11.4-55.2) months. The risk of CR was significantly higher in patients with an RS ⩾ i2 assessed by the first postoperative endoscopy compared with patients with an RS ⩽ i1 (p < 0.001). Moreover, the cumulative rate of CR was significantly higher in patients with ileal lesions (I1-4) compared with patients without (I0) (p < 0.001). Besides, patients with anastomotic lesions (A1-3) had significantly higher rates of CR than patients without (A0) (p = 0.002). A nomogram, incorporating scores of postoperative ileal or anastomotic lesions, sex, L2-subtype and perianal disease, was established. The DCA analysis indicated that the nomogram had a higher benefit for CR, especially at the timeframe of 24-60 months after index endoscopy, compared to the traditional RS score. Conclusion A nomogram incorporating postoperative ileal and anastomotic lesions separately was developed to predict CR in CD patients, which may serve as a practical tool to identify high-risk patients who need timely postoperative intervention.
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Affiliation(s)
- Shanshan Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jinshen He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Baili Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhihui Chen
- Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Road 2nd, Guangzhou 510080, China
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13
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Yang L, Liu G, Zhang Y, Yao B, Wu Q, Peng L, Wang X, Yuan L. Quantitative analysis of adipose tissue for predicting Crohn's disease postoperative endoscopic recurrence and anastomotic ulcer. Int J Colorectal Dis 2023; 38:170. [PMID: 37328584 DOI: 10.1007/s00384-023-04456-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Inflammation and ulcers at the anastomotic site are frequently observed after intestinal resection surgery for Crohn's disease (CD), which often signify postoperative recurrence. Crohn's disease causes abnormalities in whole-body fat metabolism, and alterations in subcutaneous and visceral fat are potential indicators of disease development. This study aimed to quantify the areas of subcutaneous (SFA) and visceral fat (VFA) and investigate the relationship between fat tissue and endoscopic recurrence and anastomotic ulceration after Crohn's disease surgery. METHODS We conducted a retrospective analysis of clinical data from 279 patients diagnosed with Crohn's disease. Using abdominal CT (Computed Tomography) scans at the level of the umbilicus, we measured the area of subcutaneous and visceral fat, and calculated the Mesenteric Fat Index (MFI), which is defined as the ratio of the area of visceral fat to subcutaneous fat. We compared the changes in fat tissue between surgical Crohn's disease patients and non-surgical patients in remission, as well as changes in fat tissue before and after surgery, and between patients with and without endoscopic recurrence after surgery. RESULTS The MFI value of the surgical group was higher than that of the non-surgical group(0.88(1.27 ± 1.26) VS 0.39(0.44 ± 0.21), P < 0.001), while the SFA value was lower(70.16(92.97 ± 78.23) VS 157.64(175.96 ± 101.58), P < 0.001). Of the 134 surgical patients who underwent abdominal CT examination after surgery, the SFA value was significantly higher after surgery(143.61 ± 81.86 VS 90.87 ± 71.93, P < 0.001), and the MFI value decreased accordingly(0.57 ± 0.36 VS 1.30 ± 1.35, P < 0.001). Multivariate Cox analysis indicated that high VFA and MFI values, smoking history, and preoperative biologic therapy were all risk factors for postoperative endoscopic recurrence(p < 0.05), while high MFI values and preoperative biologic therapy were also risk factors for anastomotic ulcers(p < 0.05). The Kaplan-Meier analysis showed that these factors increased the risk of reaching the endpoint with time(p < 0.05). The ROC curve results showed that MFI value had high diagnostic value for postoperative endoscopic recurrence [AUC:0.831, 95% CI: 0.75-0.91, p < 0.001] and anastomotic ulcers [AUC:0.801, 95% CI: 0.71-0.89, p < 0.001]. CONCLUSIONS Surgical CD patients have significantly higher MFI values but the values decline after surgery. When the preoperative MFI value is > 0.82, the risk of postoperative endoscopic recurrence increases significantly, and when the MFI value is ≥ 1.10, the risk of anastomotic ulceration after surgery increases significantly. Meanwhile, biologic therapy preoperatively also is a high-risk factor for early postoperative endoscopic recurrence or anastomotic ulcers after intestinal resection surgery.
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Affiliation(s)
- Lichao Yang
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Ganglei Liu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Yawei Zhang
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Baojia Yao
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Qiang Wu
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Liangxin Peng
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.
| | - Lianwen Yuan
- Department of General Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.
- Department of Geriatric Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.
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14
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Rivière P, Pekow J, Hammoudi N, Wils P, De Cruz P, Wang CP, Mañosa M, Ollech J, Allez M, Nachury M, Kamm MA, Ahanori M, Ferrante M, Buisson A, Singh S, Laharie D, Diouf M, Fumery M. Comparison of the Risk of Crohn's Disease Postoperative Recurrence Between Modified Rutgeerts Score i2a and i2b Categories: An Individual Patient Data Meta-analysis. J Crohns Colitis 2023; 17:269-276. [PMID: 36124813 DOI: 10.1093/ecco-jcc/jjac137] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The modified Rutgeerts' score [RS] differentiates i2a-lesions confined to the anastomosis-and i2b-more than five aphthous ulcers in the neoterminal ileum with normal intervening mucosa, with or without anastomotic lesions-categories. Its relevance for the therapeutic management of Crohn's disease [CD] patients after ileocolic resection is still debated. Our objective was to compare the postoperative recurrence risk in patients with an i2a or i2b score, using an individual patient data meta-analysis. METHODS We conducted a systematic literature search until July 2020, to identify all relevant studies reporting the i2a/i2b status in the year following ileocolic resection and clinical and/or surgical postoperative CD recurrence in their follow-up. Individual patient-level data were obtained from the corresponding authors. The association between the modified RS and time-to-event was evaluated using a mixed Cox model with the centre as the random effect. RESULTS Seven studies published between 2008 and 2019 were included, corresponding to 400 patients: 189 [47%] i2a and 211 [53%] i2b. Median [interquartile range, IQR] time from ileocolic resection to ileocolonoscopy was 6.2 [5.5, 7.9] months and median [IQR] follow-up time after ileocolonoscopy was 4.5 [2.9, 7.3] years. The risk of clinical postoperative recurrence at 1 and 3 years was 11% [6-15%], and 25% [18-32%] in the i2a group versus 9% [5-13%] and 33% [26-41%] in the i2b group [p = 0.63 and p = 0.12, respectively]. No significant difference was observed in terms of time to clinical postoperative recurrence [p = 0.16] or surgical postoperative recurrence [p = 0.87]. Results did not change after excluding patients having initiated an immunosuppressant or a biologic in the 3 months after endoscopy [remaining cohort, n = 361]. CONCLUSIONS In this individual patient data meta-analysis, no difference was observed between i2a and i2b subcategories with regards to clinical or surgical postoperative recurrence. As we wait for prospective trials, the same treatment strategy could be applied to all patients classified as i2 on the Rutgeerts score.
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Affiliation(s)
- Pauline Rivière
- Hôpital Haut-Lévêque, Service d'Hépato-gastroentérologie et oncologie digestive - Université de Bordeaux, Bordeaux, France
| | - Joel Pekow
- Gastroenterology Department, University of Chicago, Chicago, IL, USA
| | - Nassim Hammoudi
- Service d'Hépato-gastroentérologie, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Pauline Wils
- Univ. Lille, Institute for Translational Research in Inflammation, Lille, France
| | - Peter De Cruz
- Gastroenterology Department, Austin Health, Heidelberg, VIC, Australia
| | - Christina Pu Wang
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Míriam Mañosa
- Hospital Universitari Germans Trias i Pujol, Badalona, Catalunya, Spain
| | - Jacob Ollech
- Gastroenterology Department, University of Chicago, Chicago, IL, USA
| | - Matthieu Allez
- Service d'Hépato-gastroentérologie, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Maria Nachury
- Univ. Lille, Institute for Translational Research in Inflammation, Lille, France
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Maya Ahanori
- Gastroenterology Department, University of Chicago, Chicago, IL, USA
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Anthony Buisson
- Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Siddarth Singh
- Division of Gastroenterology and Division of Biomedical Informatics, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - David Laharie
- Hôpital Haut-Lévêque, Service d'Hépato-gastroentérologie et oncologie digestive - Université de Bordeaux, Bordeaux, France
| | - Momar Diouf
- Direction de la recherche clinique, Centre Hospitalier Universitaire Amiens-Picardie Site Sud, Amiens, France
| | - Mathurin Fumery
- Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire Amiens-Picardie Site Sud, Amiens, France
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15
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Chen R, Li C, Chao K, Tie Y, Zheng J, Guo H, Zeng Z, Li L, Chen M, Zhang S. Neutrophil-to-lymphocyte ratio for predicting postoperative recurrence in Crohn's disease patients with isolated anastomotic lesions. Therap Adv Gastroenterol 2023; 16:17562848231165129. [PMID: 37025498 PMCID: PMC10071151 DOI: 10.1177/17562848231165129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/06/2023] [Indexed: 04/08/2023] Open
Abstract
Background Patients with isolated anastomotic lesions (iAL) are common in postoperative Crohn's disease (CD) and have heterogeneous prognosis. Objectives To investigate the prognostic value of neutrophil-to-lymphocyte ratio (NLR) in CD patients with iAL. Design A bicenter retrospective cohort study. Methods CD patients who received ileocolonic resection from 2013 and 2020 and had a modified Rutgeerts score of i2a were recruited. NLR was determined within 1 week around the initial endoscopy after ileocolectomy. The primary outcome was clinical recurrence. Kaplan-Meier method and Cox hazard regression analysis were utilized to assess the association between candidate variables and outcomes of interest. Results In total, 411 postoperative CD patients were preliminarily reviewed and 83 patients were eligible. In total, 36 (48.6%) patients experienced clinical recurrence with a median follow-up time of 16.3 (interquartile range, 9.7-26.3) months. NLR > 2.45 and age at surgery >45 years had higher cumulative incidence of clinical recurrence in the Kaplan-Meier analysis. After adjusted for potential confounders, NLR > 2.45 was the only independent risk factor for clinical recurrence, with an adjusted hazard ratio (HR) of 2.88 [95% confidence interval (CI), 1.39-6.00; p = 0.005]. Furthermore, a risk score based on NLR and age at surgery were built to further stratify patients. Compared to those who scored 0, patients with a score of 1 and 2 had an adjusted HR of 2.48 (95% CI, 1.22-5.02) and 6.97 (95% CI, 2.19-22.16) for developing clinical recurrence, respectively. Conclusions NLR is a promising prognostic biomarker for CD patients with iAL. The utilization of NLR and the risk score to stratify patients may facilitate the personalized management in patients with iAL.
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Affiliation(s)
| | | | - Kang Chao
- Division of Gastroenterology, The Sixth
Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yizhe Tie
- Division of Gastroenterology, The First
Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Clinical Medicine, Zhongshan
School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Jieqi Zheng
- Division of Gastroenterology, The First
Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Clinical Medicine, Zhongshan
School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Huili Guo
- Division of Gastroenterology, The Sixth
Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhirong Zeng
- Division of Gastroenterology, The First
Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Li Li
- Division of Gastroenterology, The First
Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road 2,
Guangzhou 510080, China
| | - Minhu Chen
- Division of Gastroenterology, The First
Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road 2,
Guangzhou 510080, China
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16
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Yanai H, Kagramanova A, Knyazev O, Sabino J, Haenen S, Mantzaris GJ, Mountaki K, Armuzzi A, Pugliese D, Furfaro F, Fiorino G, Drobne D, Kurent T, Yassin S, Maharshak N, Castiglione F, de Sire R, Nardone OM, Farkas K, Molnar T, Krznaric Z, Brinar M, Chashkova E, Livne Margolin M, Kopylov U, Bezzio C, Bar-Gil Shitrit A, Lukas M, Chaparro M, Truyens M, Nancey S, Lobaton T, Gisbert JP, Saibeni S, Bacsúr P, Bossuyt P, Schulberg J, Hoentjen F, Viganò C, Palermo A, Torres J, Revés J, Karmiris K, Velegraki M, Savarino E, Markopoulos P, Tsironi E, Ellul P, Calviño Suárez C, Weisshof R, Ben-Hur D, Naftali T, Eriksson C, Koutroubakis IE, Foteinogiannopoulou K, Limdi JK, Liu E, Surís G, Calabrese E, Zorzi F, Filip R, Ribaldone DG, Snir Y, Goren I, Banai-Eran H, Broytman Y, Amir Barak H, Avni-Biron I, Ollech JE, Dotan I, Aharoni Golan M. Endoscopic Postoperative Recurrence in Crohn's Disease After Curative Ileocecal Resection with Early Prophylaxis by Anti-TNF, Vedolizumab or Ustekinumab: A Real-World Multicentre European Study. J Crohns Colitis 2022; 16:1882-1892. [PMID: 35895074 DOI: 10.1093/ecco-jcc/jjac100] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic-post-operative-recurrence [ePOR] in Crohn's disease [CD] after ileocecal resection [ICR] is a major concern. We aimed to evaluate the effectiveness of early prophylaxis with biologics and to compare anti-tumour necrosis factor [anti-TNF] therapy to vedolizumab [VDZ] and ustekinumab [UST] in a real-world setting. METHODS A retrospective multicentre study of CD-adults after curative ICR on early prophylaxis was undertaken. ePOR was defined as a Rutgeerts score [RS] ≥ i2 or colonic-segmental-SES-CD ≥ 6. Multivariable logistic regression was used to evaluate risk factors, and inverse probability treatment weighting [IPTW] was applied to compare the effectiveness between agents. RESULTS The study included 297 patients (53.9% males, age at diagnosis 24 years [19-32], age at ICR 34 years [26-43], 18.5% smokers, 27.6% biologic-naïve, 65.7% anti-TNF experienced, 28.6% two or more biologics and 17.2% previous surgery). Overall, 224, 39 and 34 patients received anti-TNF, VDZ or UST, respectively. Patients treated with VDZ and UST were more biologic experienced with higher rates of previous surgery. ePOR rates within 1 year were 41.8%. ePOR rates by treatment groups were: anti-TNF 40.2%, VDZ 33% and UST 61.8%. Risk factors for ePOR at 1 year were: past-infliximab (adjusted odds ratio [adj.OR] = 1.73 [95% confidence interval, CI: 1.01-2.97]), past-adalimumab [adj.OR = 2.32 [95% CI: 1.35-4.01] and surgical aspects. After IPTW, the risk of ePOR within 1 year of VDZ vs anti-TNF or UST vs anti-TNF was comparable (OR = 0.55 [95% CI: 0.25-1.19], OR = 1.86 [95% CI: 0.79-4.38]), respectively. CONCLUSION Prevention of ePOR within 1 year after surgery was successful in ~60% of patients. Patients treated with VDZ or UST consisted of a more refractory group. After controlling for confounders, no differences in ePOR risk were seen between anti-TNF prophylaxis and other groups.
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Affiliation(s)
- Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Anna Kagramanova
- Moscow Clinical Scientific Centre named after. A.S. Loginov, Moscow, Russian Federation
| | - Oleg Knyazev
- Moscow Clinical Scientific Centre named after. A.S. Loginov, Moscow, Russian Federation.,State Scientific Centre of Coloproctology named after A.N. Ryzhyh, Moscow, Russian Federation.,Research Institute of Health Organization and Medical Management, Moscow, Russian Federation
| | - João Sabino
- Department of Gastroenterology, University Hospitals of Leuven, Leuven, Belgium
| | - Shana Haenen
- Department of Gastroenterology, University Hospitals of Leuven, Leuven, Belgium
| | - Gerassimos J Mantzaris
- Department of Gastroenterology, GHA 'Evaggelismos-Ophthalmiatreion Athinon-Polykliniki', Athens, Greece
| | - Katerina Mountaki
- Department of Gastroenterology, GHA 'Evaggelismos-Ophthalmiatreion Athinon-Polykliniki', Athens, Greece
| | | | - Daniela Pugliese
- CEMAD, IBD UNIT, Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy
| | | | - Gionata Fiorino
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and Vita-Salute San Raffaele University, Milan, Italy
| | - David Drobne
- Department of Internal Medicine, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tina Kurent
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Sharif Yassin
- Sackler Faculty of Medicine, Tel Aviv University, Israel.,Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Nitsan Maharshak
- Sackler Faculty of Medicine, Tel Aviv University, Israel.,Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Roberto de Sire
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Olga Maria Nardone
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Klaudia Farkas
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tamas Molnar
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Centre, Zagreb, Croatia
| | - Marko Brinar
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Centre, Zagreb, Croatia
| | - Elena Chashkova
- Irkutsk Scientific Center of Surgery and Traumatology, Russia
| | - Moran Livne Margolin
- Sackler Faculty of Medicine, Tel Aviv University, Israel.,Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Uri Kopylov
- Sackler Faculty of Medicine, Tel Aviv University, Israel.,Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Israel
| | - Cristina Bezzio
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Rho (MI), Italy
| | - Ariella Bar-Gil Shitrit
- Digestive Diseases Institute, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Milan Lukas
- Clinical and Research Centre for Inflammatory Bowel Disease, ISCARE Clinical Centre, Prague, Czech Republic.,Institute of Medical Biochemistry and Laboratory Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - María Chaparro
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS- Princesa), Universidad Autónoma de Madrid (UAM), Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Marie Truyens
- IBD unit, Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium.,Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Stéphane Nancey
- Department of Gastroenterology, Lyon-Sud hospital, Hospices Civils de Lyon, Lyon and INSERM U1111, CIRI, Lyon, France
| | - Triana Lobaton
- IBD unit, Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium.,Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Javier P Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS- Princesa), Universidad Autónoma de Madrid (UAM), Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Simone Saibeni
- Gastroenterology Unit, Rho Hospital, ASST Rhodense, Rho (MI), Italy
| | - Péter Bacsúr
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Peter Bossuyt
- Imelda GI clinical Research Center, Department of Gastroenterology, Imelda General Hospital, Bonheiden, Belgium
| | - Julien Schulberg
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.,Department of Gastroenterology, Austin Hospital, Melbourne, VIC, Australia
| | - Frank Hoentjen
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands and Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Chiara Viganò
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Andrea Palermo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Joana Torres
- Division of Gastroenterology, Hospital da Luz Lisboa, Portugal.,Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Lisbon, Portugal
| | - Joana Revés
- Division of Gastroenterology, Hospital Beatriz Ângelo, Loures, Lisbon, Portugal
| | - Konstantinos Karmiris
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Magdalini Velegraki
- Department of Gastroenterology, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Edoardo Savarino
- Department of Surgical Oncological & Gastroenterological Sciences (DiSCOG), Gastroenterology Unit, Padua University, Padua, Italy
| | | | - Eftychia Tsironi
- Department of Gastroenterology, Metaxa Memorial General Hospital, Piraeus, Greece
| | - Pierre Ellul
- Division of Gastroenterology Mater Dei Hospital, Msida, Malta
| | - Cristina Calviño Suárez
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Roni Weisshof
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel
| | - Dana Ben-Hur
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel
| | - Timna Naftali
- Institute of Gastroenterology, Meir Hospital Sapir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Carl Eriksson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | | | - Jimmy K Limdi
- Department of Gastroenterology, The Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Sciences, University of Manchester, Manchester, UK
| | - Eleanor Liu
- Department of Gastroenterology, The Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Sciences, University of Manchester, Manchester, UK
| | - Gerard Surís
- Gastroenterology Department, Hospital de Bellvitge and IDIBELL, L'Hospitalet, Spain
| | - Emma Calabrese
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Italy
| | - Francesca Zorzi
- Gastroenterology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Italy
| | - Rafał Filip
- Department of Gastroenterology with IBD Unit, Clinical Hospital No. 2, Rzeszów, Poland
| | | | - Yifat Snir
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Idan Goren
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Hagar Banai-Eran
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yelena Broytman
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Hadar Amir Barak
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Irit Avni-Biron
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Jacob E Ollech
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Maya Aharoni Golan
- Department of Gastroenterology and Hepatology, Kaplan Medical Center, Rehovot, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Concord Medical Center, Clalit Health Services, Bnei Brak, Israel
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17
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Contemporary Management of Postoperative Crohn's Disease after Ileocolonic Resection. J Clin Med 2022; 11:jcm11226746. [PMID: 36431223 PMCID: PMC9693828 DOI: 10.3390/jcm11226746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/12/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022] Open
Abstract
Surgery remains an important treatment modality in the multidisciplinary management of patients with Crohn's disease (CD). To illustrate the recent advances in the management of postoperative CD we outline the contemporary approach to treatment: diagnosing disease recurrence using endoscopy or noninvasive methods and risk stratification underlying decisions to institute treatment. Endoscopic scoring indices are being refined to guide treatment decisions by accurately estimating the risk of recurrence based on endoscopic appearance. The original Rutgeerts score has been modified to separate anastomotic lesions from lesions in the neoterminal ileum. Two further indices, the REMIND score and the POCER index, were recently developed with the same intention. Noninvasive monitoring for recurrence using a method with high negative predictive value has the potential to simplify management algorithms and only perform ileocolonoscopy in a subset of patients. Fecal calprotectin, intestinal ultrasound, and magnetic resonance enterography are all being evaluated for this purpose. The use of infliximab for the prevention of postoperative recurrence is well supported by data, but management decisions are fraught with uncertainty for patients with previous exposure to biologics. Data on the use of ustekinumab and vedolizumab for postoperative CD are emerging, but controlled studies are lacking.
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18
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Hanzel J, Vuyyuru SK, Narula N, Ma C, Feagan BG, Jairath V. Case Report: Managing Postoperative Crohn's Disease. Gastroenterol Hepatol (N Y) 2022; 18:568-573. [PMID: 36397926 PMCID: PMC9666797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Jurij Hanzel
- Faculty of Medicine, University of Ljubljana and Department of Gastroenterology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Alimentiv, London, Ontario, Canada
| | - Sudheer Kumar Vuyyuru
- Alimentiv, London, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Christopher Ma
- Alimentiv, London, Ontario, Canada
- Division of Gastroenterology & Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brian G. Feagan
- Alimentiv, London, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv, London, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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19
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Bachour SP, Shah RS, Lyu R, Nakamura T, Shen M, Li T, Dane B, Barnes EL, Rieder F, Cohen B, Qazi T, Lashner B, Achkar JP, Philpott J, Holubar SD, Lightner AL, Regueiro M, Axelrad J, Baker ME, Click B. Test Characteristics of Cross-sectional Imaging and Concordance With Endoscopy in Postoperative Crohn's Disease. Clin Gastroenterol Hepatol 2022; 20:2327-2336.e4. [PMID: 34968729 PMCID: PMC9234099 DOI: 10.1016/j.cgh.2021.12.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Postoperative Crohn's disease (CD) surveillance relies on endoscopic monitoring. The role of cross-sectional imaging is less clear. We evaluated the concordance of cross-sectional enterography with endoscopic recurrence and the predictive ability of radiography for future CD postoperative recurrence. METHODS We performed a multi-institution retrospective cohort study of postoperative adult patients with CD who underwent ileocolonoscopy and cross-sectional enterography within 90 days of each other following ileocecal resection. Imaging studies were interpreted by blinded, expert CD radiologists. Patients were categorized by presence of endoscopic postoperative recurrence (E+) (modified Rutgeerts' score ≥i2b) or radiographic disease activity (R+) and grouped by concordance status. RESULTS A total of 216 patients with CD with paired ileocolonoscopy and imaging were included. A majority (54.2%) exhibited concordance (34.7% E+/R+; 19.4% E-/R-) between studies. The plurality (41.7%; n = 90) were E-/R+ discordant. Imaging was highly sensitive (89.3%), with low specificity (31.8%), in detecting endoscopic postoperative recurrence. Intestinal wall thickening, luminal narrowing, mural hyper-enhancement, and length of disease on imaging were associated with endoscopic recurrence (all P < .01). Radiographic disease severity was associated with increasing Rutgeerts' score (P < .001). E-/R+ patients experienced more rapid subsequent endoscopic recurrence (hazard ratio, 4.16; P = .033) and increased rates of subsequent endoscopic (43.8% vs 22.7%) and surgical recurrence (20% vs 9.5%) than E-/R- patients (median follow-up, 4.5 years). CONCLUSIONS Cross-sectional imaging is highly sensitive, but poorly specific, in detecting endoscopic disease activity and postoperative recurrence. Advanced radiographic disease correlates with endoscopic severity. Patients with radiographic activity in the absence of endoscopic recurrence may be at increased risk for future recurrence, and closer monitoring should be considered.
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Affiliation(s)
- Salam P Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Ravi S Shah
- Cleveland Clinic Department of Internal Medicine, Cleveland, Ohio
| | - Ruishen Lyu
- Cleveland Clinic Department of Quantitative Health Sciences, Cleveland, Ohio
| | - Takahiro Nakamura
- New York University Department of Internal Medicine, New York, New York
| | - Michael Shen
- New York University Department of Internal Medicine, New York, New York
| | - Terry Li
- New York University Department of Internal Medicine, New York, New York
| | - Bari Dane
- New York University Department of Radiology, New York, New York
| | - Edward L Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Benjamin Cohen
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Stefan D Holubar
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, Ohio
| | - Amy L Lightner
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, Ohio
| | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology, New York, New York
| | - Mark E Baker
- Cleveland Clinic Imaging Institute, Cleveland, Ohio
| | - Benjamin Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, Ohio.
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20
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Hanzel J, Jairath V, De Cruz P, Guizzetti L, Shackelton LM, Bossuyt P, Duijvestein M, Dulai PS, Grossmann J, Hirten RP, Khanna R, Panes J, Peyrin-Biroulet L, Regueiro M, Rubin DT, Singh S, Stidham RW, Sandborn WJ, Feagan BG, D'Haens GR, Ma C. Recommendations for Standardizing Clinical Trial Design and Endoscopic Assessment in Postoperative Crohn's Disease. Inflamm Bowel Dis 2022; 28:1321-1331. [PMID: 34791254 DOI: 10.1093/ibd/izab259] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND The lack of standardized methods for clinical trial design and disease activity assessment has contributed to an absence of approved medical therapies for the prevention of postoperative Crohn's disease (CD). We developed recommendations for regulatory trial design for this indication and for endoscopic assessment of postoperative CD activity. METHODS An international panel of 19 gastroenterologists was assembled. Modified Research and Development/University of California Los Angeles methodology was used to rate the appropriateness of 196 statements using a 9-point Likert scale in 2 rounds of voting. Results were reviewed and discussed between rounds. RESULTS Inclusion of patients with a history of completely resected ileocolonic CD in regulatory clinical trials for the prevention of postoperative recurrence was appropriate. Given the absence of approved medical therapies, a placebo-controlled design with a primary end point of endoscopic remission at 52 weeks was appropriate for drug development for this indication; however, there was uncertainty regarding the appropriateness of a coprimary end point of symptomatic and endoscopic remission and the use of currently available patient-reported outcome measures. The modified Rutgeerts Score, endoscopic assessment of the anastomosis, and a minimum of 5cm of neoterminal ileum were also appropriate; although the appropriateness of other indices including the Simple Endoscopic Score for CD for endoscopic assessment of postoperative CD activity was uncertain. CONCLUSIONS A framework for regulatory trial design for the prevention of postoperative CD recurrence and endoscopic assessment of disease activity has been developed. Research to empirically validate end points for these trials is needed.
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Affiliation(s)
- Jurij Hanzel
- Department of Gastroenterology, UMC Ljubljana, Ljubljana, Slovenia.,Alimentiv Inc., London, Ontario, Canada
| | - Vipul Jairath
- Alimentiv Inc., London, Ontario, Canada.,Division of Gastroenterology, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Peter De Cruz
- Department of Gastroenterology, The Austin Hospital, Melbourne, Australia.,Department of Medicine, Austin Academic Centre, University of Melbourne, Melbourne, Australia
| | | | | | - Peter Bossuyt
- Department of Gastroenterology, Imelda General Hospital, Bonheiden, Belgium
| | - Marjolijn Duijvestein
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), University of Amsterdam, Amsterdam, the Netherlands
| | - Parambir S Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Johannes Grossmann
- Department of Internal Medicine I, Bethesda Hospital, Johanniter GmbH, Mönchengladbach, Germany
| | - Robert P Hirten
- Icahn School of Medicine, The Susan & Leonard Feinstein IBD Center Division of Gastroenterology, Mount Sinai, New York City, New York, USA
| | - Reena Khanna
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Julian Panes
- Hospital Clinic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine,Vandoeuvre-lès-Nancy, France
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Ryan W Stidham
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Department of Computational Medicine and Bioinformatics. University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - William J Sandborn
- Alimentiv Inc., London, Ontario, Canada.,Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Brian G Feagan
- Alimentiv Inc., London, Ontario, Canada.,Division of Gastroenterology, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), University of Amsterdam, Amsterdam, the Netherlands
| | - Christopher Ma
- Alimentiv Inc., London, Ontario, Canada.,Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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21
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Axelrad JE, Li T, Bachour SP, Nakamura TI, Shah R, Sachs MC, Chang S, Hudesman DP, Holubar SD, Lightner AL, Barnes EL, Cohen BL, Rieder F, Esen E, Remzi F, Regueiro M, Click B. Early Initiation of Antitumor Necrosis Factor Therapy Reduces Postoperative Recurrence of Crohn's Disease Following Ileocecal Resection. Inflamm Bowel Dis 2022:6651946. [PMID: 35905032 PMCID: PMC10233395 DOI: 10.1093/ibd/izac158] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative recurrence (POR) of Crohn's disease (CD) is common after surgical resection. We aimed to compare biologic type and timing for preventing POR in adult CD patients after ileocecal resection (ICR). METHODS We performed a retrospective cohort study of CD patients who underwent an ICR at 2 medical centers. Recurrence was defined by endoscopy (≥ i2b Rutgeerts score) or radiography (active inflammation in neoterminal ileum) and stratified by type and timing of postoperative prophylactic biologic within 12 weeks following an ICR (none, tumor necrosis factor antagonists [anti-TNF], vedolizumab, and ustekinumab). RESULTS We identified 1037 patients with CD who underwent an ICR. Of 278 (26%) who received postoperative prophylaxis, 80% were placed on an anti-TNF agent (n = 223) followed by ustekinumab (n = 28, 10%) and vedolizumab (n = 27, 10%). Prophylaxis was initiated in 35% within 4 weeks following an ICR and in 65% within 4 to 12 weeks. After adjusting for factors associated with POR, compared with no biologic prophylaxis, the initiation of an anti-TNF agent within 4 weeks following an ICR was associated with a reduction in POR (adjusted hazard ratio, 0.61; 95% CI, 0.40-0.93). Prophylaxis after 4 weeks following an ICR or with vedolizumab or ustekinumab was not associated with a reduction in POR compared with those who did not receive prophylaxis. CONCLUSION Early initiation of an anti-TNF agent within 4 weeks following an ICR was associated with a reduction in POR. Vedolizumab or ustekinumab, at any time following surgery, was not associated with a reduction in POR, although sample size was limited.
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Affiliation(s)
- Jordan E Axelrad
- Divison of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Terry Li
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Salam P Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Takahiro I Nakamura
- Divison of Gastroenterology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Ravi Shah
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael C Sachs
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Shannon Chang
- Divison of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - David P Hudesman
- Divison of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Edward L Barnes
- Divison of Gastroenterology, Department of Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Eren Esen
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Feza Remzi
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Click
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
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22
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Kim KO. Endoscopic activity in inflammatory bowel disease: clinical significance and application in practice. Clin Endosc 2022; 55:480-488. [PMID: 35898147 PMCID: PMC9329646 DOI: 10.5946/ce.2022.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 04/26/2022] [Indexed: 11/14/2022] Open
Abstract
Endoscopy is vital for diagnosing, assessing treatment response, and monitoring surveillance in patients with inflammatory bowel disease (IBD). With the growing importance of mucosal healing as a treatment target, the assessment of disease activity by endoscopy has been accepted as the standard of care for IBD. There are many endoscopic activity indices for facilitating standardized reporting of the gastrointestinal mucosal appearance in IBD, and each index has its strengths and weaknesses. Although most endoscopic indices do not have a clear-cut validated definition, endoscopic remission or mucosal healing is associated with favorable outcomes, such as a decreased risk of relapse. Therefore, experts suggest utilizing endoscopic indices for monitoring disease activity and optimizing treatment to achieve remission. However, the regular monitoring of endoscopic activity is limited in practice owing to several factors, such as the complexity of the procedure, time consumption, inter-observer variability, and lack of a clear-cut, validated definition of endoscopic response or remission. Although experts have recently suggested consensus-based definitions, further studies are needed to define the values that can predict long-term outcomes.
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Affiliation(s)
- Kyeong Ok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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23
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Bachour SP, Shah RS, Rieder F, Qazi T, Achkar JP, Philpott J, Lashner B, Holubar SD, Lightner AL, Barnes EL, Axelrad J, Regueiro M, Click B, Cohen BL. Intra-abdominal septic complications after ileocolic resection increases risk for endoscopic and surgical postoperative Crohn's disease recurrence. J Crohns Colitis 2022; 16:1696-1705. [PMID: 35705188 PMCID: PMC9924045 DOI: 10.1093/ecco-jcc/jjac078] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Postoperative recurrence [POR] of Crohn's disease following ileocolonic resection is common. The impact of immediate postoperative intra-abdominal septic complications [IASC] on endoscopic and surgical recurrence has not been elucidated. AIMS To evaluate if IASC is associated with an increased risk for endoscopic and surgical POR. METHODS This was a retrospective study of adult Crohn's disease patients undergoing ileocolonic resection with primary anastomosis between 2009 and 2020. IASC was defined as anastomotic leak or intra-abdominal abscess within 90 days of the date of surgery. Multivariable logistic and Cox proportional hazard modelling were performed to assess the impact of IASC on endoscopic POR [modified Rutgeerts' score ≥ i2b] at index postoperative ileocolonoscopy and long-term surgical recurrence. RESULTS In 535 Crohn's disease patients [median age 35 years, 22.1% active smokers, 35.7% one or more prior resection] had an ileocolonic resection with primary anastomosis. A minority of patients [N = 47; 8.8%] developed postoperative IASC. In total, 422 [78.9%] patients had one or more postoperative ileocolonoscopies, of whom 163 [38.6%] developed endoscopic POR. After adjusting for other risk factors for postoperative recurrence, postoperative IASC was associated with significantly greater odds (adjusted odds ratio [aOR]: 2.45 [1.23-4.97]; p = 0.01) and decreased time (adjusted hazards ratio [aHR]: 1.60 [1.04-2.45]; p = 0.03] to endoscopic POR. Furthermore, IASC was associated with increased risk (aOR: 2.3 [1.04-4.87] p = 0.03) and decreased survival-free time [aHR: 2.53 [1.31-4.87]; p = 0.006] for surgical recurrence. CONCLUSION IASC is associated with an increased risk for endoscopic and surgical POR of Crohn's disease. Preoperative optimization to prevent IASC, in addition to postoperative biological prophylaxis, may help reduce the risk for endoscopic and surgical POR.
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Affiliation(s)
- Salam P Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Ravi S Shah
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH, USA
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Stefan D Holubar
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, OH, USA
| | - Amy L Lightner
- Cleveland Clinic Department of Colorectal Surgery, Cleveland, OH, USA
| | - Edward L Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology, New York, NY, USA
| | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Benjamin Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, Cleveland, OH, USA
| | - Benjamin L Cohen
- Correspondence: Benjamin L. Cohen, MD, MAS, Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition, 9500 Euclid Ave., A30, Cleveland, OH, 44195, USA.
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24
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Bachour SP, Shah RS, Lyu R, Rieder F, Qazi T, Lashner B, Achkar JP, Philpott J, Barnes EL, Axelrad J, Holubar SD, Lightner AL, Regueiro M, Cohen BL, Click BH. Mild neoterminal ileal post-operative recurrence of Crohn's disease conveys higher risk for severe endoscopic disease progression than isolated anastomotic lesions. Aliment Pharmacol Ther 2022; 55:1139-1150. [PMID: 35285534 PMCID: PMC9677520 DOI: 10.1111/apt.16804] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 12/15/2022]
Abstract
There are conflicting data assessing the impact of isolated post-operative anastomotic inflammation on future disease progression. The aim of this study was to determine the relative risk of severe disease progression in post-operative Crohn's disease (CD) patients with isolated anastomotic disease. METHODS Retrospective cohort study of adult CD patients undergoing ileocolonic resection between 2009 and 2020. Patients with a post-operative ileocolonoscopy ≤18 months from surgery and ≥1 subsequent ileocolonoscopy were included. Disease activity was assessed using the modified Rutgeerts' score (RS). Primary outcome was severe endoscopic progression, defined as i3 or i4 disease, on immediate subsequent ileocolonoscopy and during entire post-operative follow-up. Secondary outcome was surgical recurrence. RESULTS One hundred and ninety-nine CD patients had an ileocolonoscopy ≤18 months from surgery, index RS of i0-i2b and ≥1 subsequent ileocolonoscopy. At index ileocolonoscopy, 34.7% had i0 disease, 16.1% i1, 24.6% i2a and 24.6% i2b. On multivariable logistic regression, i2b disease was associated with severe endoscopic progression compared to i0 or i1 (aOR 5.53; P < 0.001) and i2a disease patients (aOR 2.63; P = 0.03). However, i2a disease did not confer increased risk compared to i0 or i1 disease (P = 0.09). Furthermore, i2b patients experienced severe endoscopic progression significantly earlier than i0 or i1 disease (aHR 4.68; P < 0.001), whereas i2a disease did not differ from i0 or i1 disease (P = 0.25). Surgical recurrence was not associated with index RS i0-i2b (P = 0.86). CONCLUSION Post-operative ileal disease recurrence, not isolated anastomotic inflammation, confers increased risk for severe endoscopic disease progression. Location of CD recurrence may impact optimal management strategies.
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Affiliation(s)
- Salam P. Bachour
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
| | - Ravi S. Shah
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Ruishen Lyu
- Cleveland Clinic Department of Quantitative Health Sciences
| | - Florian Rieder
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition,Department of Inflammation and Immunity, Lerner Research Institute
| | - Taha Qazi
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Bret Lashner
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Jean Paul Achkar
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Jessica Philpott
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Edward L. Barnes
- University of North Carolina at Chapel Hill, Division of Gastroenterology and Hepatology
| | - Jordan Axelrad
- New York University Department of Gastroenterology and Hepatology
| | | | | | - Miguel Regueiro
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Benjamin L. Cohen
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
| | - Benjamin H. Click
- Cleveland Clinic Department of Gastroenterology, Hepatology, and Nutrition
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25
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Guo Z, Zhu Y, Xu Y, Cao L, Li Y, Gong J, Wang Z, Zhu W. Endoscopic Evaluation at 1 Month After Ileocolic Resection for Crohn's Disease Predicts Future Postoperative Recurrence and Is Safe. Dis Colon Rectum 2022; 65:382-389. [PMID: 34759245 DOI: 10.1097/dcr.0000000000002012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopy remains the gold standard for evaluating postoperative recurrence in Crohn's disease. Timely therapy adjustment according to endoscopic findings can improve long-term outcomes. OBJECTIVE We aimed to determine the characteristics, clinical values, and safety of the endoscopic evaluation at 1 month after surgery. DESIGN This was a prospective observational study. SETTINGS This study was conducted in a tertiary referral hospital. PATIENTS Patients with Crohn's disease undergoing ileocolic resection between January 2016 and November 2018 were included. INTERVENTIONS The first postoperative ileocolonoscopy was performed at 4-5 weeks after surgery. MAIN OUTCOME MEASURES The primary outcome was postoperative recurrence within 12 months after surgery. Univariate and multivariate analyses were performed to identify risk factors. RESULTS Among 84 ileocolonoscopies at 4-5 weeks, no endoscopic complication occurred. The main endoscopic findings at the first evaluation were anastomotic circumferential ulcers (10, 11.9%), anastomotic scattered ulcers (35, 41.7%), ulcers in the neoterminal ileum (16, 19.0%), edema in anastomosis (50, 59.5%), mild narrowing in anastomosis (7, 8.3%), and mild narrowing in neoterminal ileum (3, 3.6%). Anastomotic scattered ulcers were associated with future postoperative recurrence (OR, 2.532 (95% CI, 1.02-6.32), p = 0.046). Fecal calprotectin >150 ug/g on postoperative day 14 could predict anastomotic scattered ulcers (OR' 2.91 (95% CI, 1.31-7.47), p = 0.027). The modified Rutgeerts score was used to define endoscopic findings: i0, 37 (44.0%); i1, 4 (4.8%); i2a, 29 (34.5%); i2b, 11 (13.1%); i3, 0; i4, 3 (3.6%). Score ≥i2a were associated with future postoperative recurrence (OR, 3.17 (95% CI, 1.22-8.27), p = 0.018). No factor was associated with a Rutgeerts score of ≥i2a at the first endoscopic evaluation. LIMITATIONS This was a single-center study with a small cohort of patients. CONCLUSIONS Endoscopic evaluation at 1 month after surgery in CD was safe. Anastomotic scattered ulcers occurred in nearly half of patients and were associated with future postoperative recurrence. See Video Abstract at http://links.lww.com/DCR/B760.LA EVALUACIÓN ENDOSCÓPICA A UN MES DESPUÉS DE LA RESECCIÓN ILEOCÓLICA PARA LA ENFERMEDAD DE CROHN, PREDICE FUTURA RECURRENCIA POSOPERATORIA Y ES SEGURAANTECEDENTES:La endoscopia sigue siendo el estándar de oro para evaluar la recurrencia posoperatoria en la enfermedad de Crohn (EC). El ajuste oportuno en la terapia de acuerdo con los hallazgos endoscópicos, puede mejorar los resultados a largo plazo.OBJETIVO:Determinar las características, valores clínicos y seguridad de la evaluación endoscópica, al mes de la cirugía.DISEÑO:Estudio observacional prospectivo.ENTORNO CLINICO:El estudio se llevó a cabo en un hospital de referencia terciario.PACIENTES:Se incluyeron pacientes con EC sometidos a resección ileocólica entre enero de 2016 y noviembre de 2018.INTERVENCIONES:La primera ileocolonoscopia posoperatoria se realizó a las 4-5 semanas posteriores a la cirugía.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la recurrencia posoperatoria dentro de los 12 meses posteriores a la cirugía. Se realizaron análisis univariados y multivariados para identificar factores de riesgo.RESULTADOS:Entre 84 ileocolonoscopias a las 4-5 semanas, no ocurrió ninguna complicación endoscópica. Los principales hallazgos endoscópicos en la primera evaluación, fueron úlceras anastomóticas circunferenciales (10, 11,9%), úlceras anastomóticas dispersas (35, 41,7%), úlceras en el íleon neo-terminal (16, 19,0%), edema en la anastomosis (50, 59,5%), estrechamiento leve en la anastomosis (7, 8,3%) y estrechamiento leve en el íleon neo-terminal (3, 3,6%). Las úlceras anastomóticas dispersas se asociaron con recurrencia posoperatoria futura (OR, 2,532 (95% CI, 1,02-6,32), p = 0,046). La calprotectina fecal en el post d 14 > 150 ug / g podría predecir úlceras anastomóticas dispersas (OR' 2,91 (95% CI, 1,31-7,47), p = 0,027). Se utilizó la puntuación de Rutgeerts modificada para definir los hallazgos endoscópicos: i0, 37 (44,0%); i1, 4 (4,8%); i2a, 29 (34,5%); i2b, 11 (13,1%); i3, 0; i4, 3 (3,6%). La puntuación ≥i2a se asoció con recurrencia posoperatoria futura (OR, 3,17 (95% CI, 1,22-8,27), p = 0,018). Ningún factor se asoció con ≥i2a en la primera endoscopia.LIMITACIONES:Estudio de un solo centro con una pequeña cohorte de pacientes.CONCLUSIONES:La evaluación endoscópica al mes de la cirugía en EC, fue segura. Se produjeron úlceras anastomóticas dispersas en casi la mitad de los pacientes y se asociaron con una futura recurrencia posoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B760. (Traducción - Dr. Fidel Ruiz Healy).
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Affiliation(s)
- Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Yipeng Zhu
- Nanjing Medical University, Nanjing, P.R. China
| | - Yihan Xu
- Nanjing Medical University, Nanjing, P.R. China
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Zhiming Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
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26
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Cohen NA, Pekow J. Editorial: time to modify practice and use the modified Rutgeert's score. Aliment Pharmacol Ther 2022; 55:754-755. [PMID: 35245961 DOI: 10.1111/apt.16821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/09/2022]
Affiliation(s)
| | - Joel Pekow
- IBD Center, University of Chicago Medicine, Chicago, Illinois, USA
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27
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Dasharathy SS, Limketkai BN, Sauk JS. What's New in the Postoperative Management of Crohn's Disease? Dig Dis Sci 2022; 67:3508-3517. [PMID: 34406585 PMCID: PMC9287204 DOI: 10.1007/s10620-021-07205-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/26/2021] [Indexed: 12/14/2022]
Abstract
Patients with Crohn's disease (CD) often require surgical resection due to complications, such as strictures and abscesses, or disease refractory to medical therapy. To understand the evolving management of patients with CD after surgery, we outline the risk factors for postoperative recurrence, advances in postoperative endoscopic evaluation and characterization of recurrence, noninvasive methods of assessing postoperative recurrence, use of postoperative prophylactic medical therapy including newer biologics, and novel surgical methods to reduce postoperative recurrence. The Rutgeerts score (RS) was developed to predict progression of disease based on endoscopic appearance postoperatively and to guide medical therapy. However, this scoring system groups ileal and anastomotic lesions into the same category. A modified RS was developed to separate lesions isolated to the anastomosis and those in the neo-terminal ileum to further understand the role of anastomotic lesions in CD progression. Additional scoring systems have also been evaluated to better understand these differences. In addition, noninvasive diagnostic methods, such as small bowel ultrasound, have high sensitivity and specificity for the detection of postoperative recurrence and are being evaluated as independent methods of assessment. Studies have also shown a reduction in endoscopic recurrence with postoperative anti-TNFα therapy. However, preoperative exposure to anti-TNFα therapy may impact postoperative response to these medications, and therefore, determining optimal postoperative prophylaxis strategy for biologic-experienced patients requires further exploration. Lastly, new surgical modalities to reduce postoperative recurrence are currently being investigated with preliminary data suggesting that an antimesenteric functional end-to-end anastomosis (Kono-S) may decrease postoperative recurrence.
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Affiliation(s)
- Sonya S Dasharathy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Berkeley N Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Jenny S Sauk
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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28
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Akiyama S, Yamada A, Ollech JE, Komaki Y, Komaki F, Pekow J, Dalal SR, Cohen RD, Rubin DT, Sakuraba A. Predictability of simple endoscopic score for Crohn's disease for postoperative outcomes in Crohn's disease. J Gastroenterol Hepatol 2021; 36:2785-2793. [PMID: 33973282 DOI: 10.1111/jgh.15540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/21/2021] [Accepted: 05/07/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND AIM Approximately half of patients with Crohn's disease (CD) who have surgery will experience clinical recurrence within 10 years of their surgery. This study aimed to assess the postoperative outcomes according to disease location and validated the simple endoscopic score for CD (SES-CD) to predict disease-related outcomes. METHODS We retrospectively assessed medical records of CD patients who underwent ileocolonoscopy within 12 months after surgery at the University of Chicago between 2005 and 2016. We defined patients with postoperative colonic inflammation at the first postoperative ileocolonoscopy or had Montreal classification L2 as colon-dominant disease and patients without colonic involvement or who had L1 as small intestine (SI)-dominant disease. The outcomes included clinical and surgical recurrence. RESULTS Among 207 CD patients, 51 (24.6%) and 156 (75.4%) patients had colon-dominant and SI-dominant disease, respectively. Patients with colon-dominant disease had a greater risk of postoperative clinical recurrence compared with those with SI-dominant disease (P = 0.018). Colon-dominant disease was a risk of earlier surgical recurrence compared with SI-dominant disease, although there were no significant differences in the recurrence-free survivals. SES-CD > 2 at the first postoperative ileocolonoscopy was a significant risk of clinical recurrence on log-rank test (P < 0.001) and Cox proportional hazards model (hazard ratio = 2.25; 95% confidence interval = 1.14-4.47; P = 0.020). An SES-CD of 1 was an appropriate cut-off to predict the clinical recurrence of SI-dominant disease, but a higher SES-CD cut-off value of 5 was required for colon-dominant disease. CONCLUSIONS We demonstrated that SES-CD predicts postoperative clinical recurrence of CD, regardless of disease location.
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Affiliation(s)
- Shintaro Akiyama
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Akihiro Yamada
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Section of Gastroenterology, Department of Internal Medicine, Toho University Sakura Medical Center, Chiba, Japan
| | - Jacob E Ollech
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Inflammatory Bowel Disease Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yuga Komaki
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Fukiko Komaki
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA.,Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Joel Pekow
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sushila R Dalal
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Russell D Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Atsushi Sakuraba
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois, USA
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29
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The Clinical Significance of Anastomotic Ulcers After Ileocolic Resection to Predict Postoperative Recurrence of Crohn's Disease. Dig Dis Sci 2021; 66:3132-3140. [PMID: 32926261 DOI: 10.1007/s10620-020-06599-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 09/01/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Rutgeerts score is used to predict postoperative recurrence in CD patients after ileocolic resection and is primarily based on endoscopic findings at the neoterminal ileum. However, the optimal assessment of anastomotic ulcers (AUs) remains subject to debate. AIMS We aimed to investigate the association between anastomotic ulcers (AUs) and endoscopic recurrence in postoperative Crohn's disease (CD) patients. METHODS This single-center retrospective study, conducted between 2000 and 2016, evaluated postoperative CD patients with endoscopic remission at the first ileocolonoscopy within 1 year after ileocolic resection and those who underwent subsequent ileocolonoscopic follow-up. The study outcome was the clinical significance of AUs in predicting endoscopic recurrence. RESULTS Among 116 patients who were in endoscopic remission defined as the RS of i0 to i1 at the index postoperative ileocolonoscopy, 84.5% (98/116) underwent subsequent ileocolonoscopies. During the median 30.0 months (interquartile range, 21.3-53.3) of follow-up after the first ileocolonoscopy, 56.1% (55/98) of patients showed endoscopic recurrence. Furthermore, 65.8% (48/73) with AUs and 75.5% (40/53) with major AUs, defined as either an ulcer occupying ≥ 1/4 of the circumference, ≥ 3 ulcers confined to anastomotic ring, or any ulcers extending to the ileocolonic mucosa, showed endoscopic recurrence. On multivariable analysis, AUs (adjusted hazard ratio [aHR], 4.33; 95% confidence interval [CI], 1.87-10.0; P < 0.001) and major AUs (aHR, 3.64; 95% CI, 1.95-79; P < 0.001) were associated with endoscopic recurrence. CONCLUSIONS AUs are associated with a significantly high risk of endoscopic recurrence in postoperative CD patients who are in endoscopic remission.
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Liu C, Li N, Zhan S, Tian Z, Wu D, Li T, Zeng Z, Zhuang X. Anti -TNFα agents in preventing the postoperative recurrence of Crohn's disease: Do they still play a role in the biological era? Expert Opin Biol Ther 2021; 21:1509-1524. [PMID: 34350811 DOI: 10.1080/14712598.2021.1964469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Approximately half of patients with Crohn's disease (CD) may inevitably receive surgical intervention as the disease progress. However, about 75% of CD patients will experience postoperative recurrence (POR). Biologics are appealing alternatives for the prevention of POR; however, it is still unclear which biological agents are more efficient. This meta-analysis aimed to investigate the efficacy of biologics for POR prevention and to compare the superiority of different biologics. METHODS We conducted a thorough search of online databases and screened for studies on the efficacy of biologics in preventing POR (clinical, endoscopic, or histological) that were published until January 2021. The results were presented as forest plots and odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS We included 26 studies with 2,136 participants. Overall, biologics were more efficient over non-biological treatments in preventing endoscopic, severe endoscopic, and clinical POR without increasing the frequency of adverse events. Among the various types of biologics, anti-TNFα agents were better than vedolizumab in preventing endoscopic POR. Moreover, infliximab had a similar curative effect to adalimumab in preventing endoscopic, severe endoscopic, and clinical recurrence. CONCLUSION Biologics, especially anti-TNFα agents, still play a vital role in preventing POR in the biological era.
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Affiliation(s)
- Caiguang Liu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Na Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shukai Zhan
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenyi Tian
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Dongxuan Wu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Tong Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaojun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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Tandon P, Malhi G, Abdali D, Pogue E, Marshall JK, de Buck van Overstraeten A, Riddell R, Narula N. Active Margins, Plexitis, and Granulomas Increase Postoperative Crohn's Recurrence: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2021; 19:451-462. [PMID: 32801016 DOI: 10.1016/j.cgh.2020.08.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Rates of postoperative Crohn's disease recurrence remain high, although the ability to predict this risk of recurrence remains limited. As such, we aimed to determine the association of histologic features at the time of resection with postoperative recurrence. METHODS Electronic databases were searched through February 2020 for studies that reported risk of clinical, endoscopic, or surgical postoperative recurrence in patients with positive resection margins, plexitis, or granulomas in the index specimen. Pooled risk ratios (RRs) with 95% CIs were calculated for this risk in patients with and without these histologic features. RESULTS Twenty-one studies (2481 patients) assessed positive resection margins, 10 studies (808 patients) assessed plexitis, and 19 studies (1777 patients) assessed granulomas. Positive resection margins increased the risk of clinical (RR, 1.26; 95% CI, 1.06-1.49; I2 = 41%) and surgical (RR, 1.87; 95% CI, 1.14-3.08; I2 = 71%) recurrence, with a trend toward endoscopic recurrence (RR, 1.56; 95% CI, 0.79-3.05; I2 = 85%). Granulomas increased the risk of clinical (RR, 1.31; 95% CI, 1.05-1.64; I2 = 36%) and endoscopic (RR, 1.37; 95% CI, 1.00-1.87; I2 = 49%) recurrence, with a trend toward surgical recurrence (RR, 1.58; 95% CI, 0.89-2.80; I2 = 75%). Plexitis increased the risk of endoscopic recurrence (RR, 1.31; 95% CI, 1.00-1.72; I2 = 20%), with a trend toward clinical recurrence (RR, 1.34; 95% CI, 0.95-1.91; I2 = 46%). CONCLUSIONS Positive resection margins, granulomas, and plexitis are predictive of postoperative Crohn's disease recurrence and should be recorded at the time of index resection.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gurpreet Malhi
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Daniyal Abdali
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Elahn Pogue
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | | | - Robert Riddell
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Neeraj Narula
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada.
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Zarauza Soto Y, Suárez Ferrer C, Poza Cordón J, Martín Arranz E, Crivillén Anguita O, Rueda García JL, Sanchez Azofra M, García Ramírez L, Martín Arranz MD. Is the degree of i2a recurrence in Crohn's disease secondary to ischemic phenomena? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:246-250. [PMID: 33207884 DOI: 10.17235/reed.2020.6790/2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION the Rutgeerts score is used to assess post-surgical recurrence of Crohn's disease (CD). The score initially consisted of four grades, with a subsequent sub-classification of grade 2, under which ulcers confined to the anastomosis (i2a) are considered to be of a probable ischemic origin. The aim of this study was to assess whether ulcers confined to the anastomosis appear at the same frequency in patients undergoing surgery for other causes and can therefore be attributed to post-surgical changes. MATERIAL AND METHODS this was a retrospective cohort study with patients who had undergone colonoscopy as per clinical practice between 2017 and 2018. There were two cohorts, one cohort of patients to assess the post-surgical recurrence of CD and another cohort for follow-up after colorectal cancer (CRC) treated with ileocolonic anastomosis. RESULTS a total of 185 patients were included; 33 % had undergone surgery for CD and 67 % had undergone surgery for CRC. Fifty-six percent of patients were male. Of the patients in the group with ulcers confined to the anastomosis, 75 % had CD and 25 % had been operated on for CRC; the difference was statistically significant (p < 0.0001). In turn, of the patients operated on for CRC, 95 % had no anastomotic lesions compared to 18 % of patients with CD. These differences reached statistical significance (p < 0.0001). CONCLUSIONS In our experience, the occurrence of ulcers on the ileocolonic anastomosis is uncommon in patients that have undergone surgery for CRC, in comparison to patients operated on due to CD. It is possible that these alterations in CD cannot therefore be attributed to solely ischemic or post-surgical phenomena.
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Vespa E, Furfaro F, Allocca M, Fiorino G, Correale C, Gilardi D, Argollo M, Zilli A, Zacharopoulou E, Loy L, Danese S. Endoscopy after surgery in inflammatory bowel disease: Crohn's disease recurrence and pouch surveillance. Expert Rev Gastroenterol Hepatol 2020; 14:829-841. [PMID: 32758015 DOI: 10.1080/17474124.2020.1807325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Crohn's disease (CD) and ulcerative colitis (UC) are immune-mediated disorders characterized by a chronic inflammation, with intermittent exacerbations of symptoms and inflammation. In both diseases, medical treatment has made revolutionary steps forward. Nevertheless, surgery is still required in many cases due to inefficacy of multiple medical therapies. It is not clear whether surgery rates in inflammatory bowel diseases (IBD) are currently decreasing despite all improvements. AREAS COVERED Multidisciplinary management is critical in surgical patients to improve long-term outcomes. Endoscopy plays a crucial role, both before and after surgery, in planning therapeutic strategies and stratifying risk of recurrence. Aim of this review is to provide a deeper insight into the central role of endoscopy in the postoperative management of IBD patients, focusing on recent research advances, future challenges and unresolved questions. EXPERT OPINION Both UC and CD surgical patients need endoscopy to define the correct therapeutic choice, predict subsequent disease course and adopt the correct surveillance strategy. In the next future, newer endoscopic techniques could be systematically applied in IBD patients after surgery, to assess early postoperative inflammation, response to treatment, or, regarding UC, to provide enhanced pouch surveillance, allowing for early detection of inflammation and dysplasia.
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Affiliation(s)
- Edoardo Vespa
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy.,Department of Biomedical Sciences, Humanitas University , Milan, Italy
| | - Federica Furfaro
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Mariangela Allocca
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy.,Department of Biomedical Sciences, Humanitas University , Milan, Italy
| | - Gionata Fiorino
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy.,Department of Biomedical Sciences, Humanitas University , Milan, Italy
| | - Carmen Correale
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Daniela Gilardi
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Marjorie Argollo
- IBD Unit, Department of Gastroenterology, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Alessandra Zilli
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Eirini Zacharopoulou
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Laura Loy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS , Rozzano (Mi), Italy.,Department of Biomedical Sciences, Humanitas University , Milan, Italy
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Hammoudi N, Auzolle C, Tran Minh ML, Boschetti G, Bezault M, Buisson A, Pariente B, Treton X, Seksik P, Fumery M, Le Bourhis L, Nancey S, Allez M. Postoperative Endoscopic Recurrence on the Neoterminal Ileum But Not on the Anastomosis Is Mainly Driving Long-Term Outcomes in Crohn's Disease. Am J Gastroenterol 2020; 115:1084-1093. [PMID: 32618659 DOI: 10.14309/ajg.0000000000000638] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Early ileocolonoscopy within the first year after surgery is the gold standard to evaluate recurrence after ileocolonic resection for Crohn's disease (CD). The aim of the study was to evaluate the association between the presence and severity of anastomotic and ileal lesions at early postoperative ileocolonoscopy and long-term outcomes. METHODS The REMIND group conducted a prospective multicenter study. Patients operated for ileal or ileocolonic CD were included. An ileocolonoscopy was performed 6 months after surgery. An endoscopic score describing separately the anastomotic and ileal lesions was built. Clinical relapse was defined by the CD-related symptoms, confirmed by imaging, endoscopy or therapeutic intensification; CD-related complications; or subsequent surgery. RESULTS Among 225 included patients, long-term follow-up was available in 193 (median follow-up: 3.82 years [interquartile range: 2.56-5.41]). Median clinical recurrence-free survival was 47.6 months. Clinical recurrence-free survival was significantly shorter in patients with ileal lesions at early postoperative endoscopy whatever their severity was (I(1) or I(2,3,4)) as compared to patients without ileal lesions (I(0)) (I(0) vs I(2,3,4): P = 0.0003; I(0) vs I(1): P = 0.0008 and I(1) vs I(2,3,4): P = 0.43). Patients with exclusively ileal lesions (A(0)I(1,2,3,4)) had poorer clinical long-term outcomes than patients with exclusively anastomotic lesions (A(1,2,3)I(0)) (P = 0.009). DISCUSSION A score describing separately the anastomotic and ileal lesions might be more appropriate to define postoperative endoscopic recurrence. Our data suggest that patients with ileal lesions, including mild ones (I(1)), could beneficiate from treatment step-up to improve long-term outcomes.
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Affiliation(s)
- Nassim Hammoudi
- Gastroenterology Department, AP-HP, Hôpital Saint-Louis, Paris, France
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - Claire Auzolle
- Gastroenterology Department, AP-HP, Hôpital Saint-Louis, Paris, France
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - My-Linh Tran Minh
- Gastroenterology Department, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Gilles Boschetti
- Gastroenterology Department, Hospices Civils de Lyon, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | - Madeleine Bezault
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - Anthony Buisson
- Université Clermont Auvergne, Inserm U1071, M2iSH, 3iHP, CHU Clermont-Ferrand, Service de Médecine de l'Appareil Digestif, Clermont-Ferrand, France
| | - Benjamin Pariente
- Gastroenterology Department, Hôpital Claude Huriez, University of Lille 2, Lille, France
| | - Xavier Treton
- Hôpital Beaujon, Service de Gastroentérologie, MICI et Assistance Nutritive, Clichy, France
| | - Philippe Seksik
- Sorbonne Universités, Department of Gastroenterology, Saint Antoine Hospital, AP-HP, Ecole normale supérieure, PSL Research University, CNRS, INSERM, Laboratoire des Biomolécules (LBM), Paris, France
| | - Mathurin Fumery
- Gastroenterology Department, Amiens University Hospital, and Peritox, UMR-I 01, Université de Picardie Jules Verne, Amiens, France
| | - Lionel Le Bourhis
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - Stéphane Nancey
- Gastroenterology Department, Hospices Civils de Lyon, Lyon, France
- University Claude Bernard Lyon 1, Lyon, France
| | - Matthieu Allez
- Gastroenterology Department, AP-HP, Hôpital Saint-Louis, Paris, France
- INSERM UMRS 1160, Université Paris Diderot, Sorbonne Paris-Cité University, Paris, France
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Mohan HM, Coffey JC. Surgical treatment of intestinal stricture in inflammatory bowel disease. J Dig Dis 2020; 21:355-359. [PMID: 32410340 DOI: 10.1111/1751-2980.12880] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
Fibroblast infiltration and collagen deposition result in structural changes in the bowel wall, and lead to strictures in intestinal inflammatory disease. While strictures can also occur in other contexts, such as malignancy, this review focuses on the surgical treatment of stricture secondary to inflammatory bowel disease. Distinguishing between predominantly inflammation vs established fibrosis as the cause of a stricture can be challenging. While inflammatory strictures may be responsive to medication, predominantly fibrotic strictures usually need surgical intervention. Both endoluminal and extraluminal approaches are described in this review. Endoscopic dilatation of strictures is suitable for short-segment isolated small bowel strictures. Other options are to divide the stricture surgically but preserve the length, performing a strictureplasty or resecting the strictured segment. The mesentery is increasingly recognized as playing a role in stricture recurrence. In a relapsing-remitting disease such as Crohn's disease, the preservation of intestinal length is essential and balance is needed between this and a complete resection to reduce the risk of recurrence. Pre- and postoperative involvement of the multidisciplinary team is essential to improve outcomes in this challenging clinical scenario.
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Affiliation(s)
- Helen M Mohan
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - John C Coffey
- Department of Surgery, University Hospital Limerick, Limerick, Ireland.,University of Limerick Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity, Limerick, Ireland
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Postoperative Crohn's disease management: still learning and evolving. Gastrointest Endosc 2019; 90:276-277. [PMID: 31327339 DOI: 10.1016/j.gie.2019.04.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/07/2019] [Indexed: 12/11/2022]
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